Gary M. Owens, M.D., and Chesahna Kindred, M.D., MBA, FAAD, discuss how an optimal multidisciplinary care model for patients with vitiligo can be achieved among providers, pharmacists and payers.
Dr. Heather Woolery-Lloyd: Now we’re going to change gears and talk about multidisciplinary care when it comes to vitiligo. We have providers, we have pharmacists, and we have payers. The question is, (Dr. Owens), for you. How can an optimal multidisciplinary care model for patients with vitiligo be achieved with the provider, the pharmacist and the payer?
Dr. Gary M. Owens: Well, let’s start with the provider and where we probably need to start. I’m a primary care physician, my background before I had my second and now my third career in other areas. I think primary care physicians for so long have not thought a lot about vitiligo. Many primary care docs, when they see a patient with vitiligo, say, “It’s vitiligo, there’s not much we can do about it. You can see a dermatologist if you want.” A lot of those patients never go on to seek additional treatment. Now, fast-forward to 2023. When we do have more effective treatments, I think it becomes very important to begin to educate the internists and the pediatricians, the family physicians out there that there are effective treatments that are safe, and as we heard from (Dr. Kindred), the long-term data (are) showing that it’s a pretty safe and effective treatment. Educating people to make appropriate referrals to dermatology is number one. I think number two, we’ve heard it in the previous aspects of this conversation, a lot of these patients have other associated autoimmune comorbidities. You want to make sure you’re coordinating that care with somebody who may be taking care of a nondermatologic autoimmune condition. Some of these patients could have rheumatoid arthritis, for instance. A lot of them do have autoimmune skin diseases, which will be right in the wheelhouse of the dermatology again, such as AD (atopic dermatitis). I think you have to coordinate care across multiple specialists for some of these patients. Even more importantly, we heard about some of the mental health issues associated with this disease and making sure that if you identify, say, a major depressive disorder or other mental health condition, that appropriate care is directed in that direction as well. What you get there is a team approach. A pharmacist can play a role in educating people about the side effects of JAK (Janus kinase) inhibitors, as well as how JAK inhibitors work. I think we’re looking at a new era where you have to be cognizant (that) it’s not just vitiligo. These patients have more and other comorbidities that need to be managed and probably need other expertise to help them manage all of that.
Dr. Heather Woolery-Lloyd: (Dr. Kindred), in your practice? I know we write a prescription, but then there are many steps from the time we write the prescription until the patient gets the medication. In your practice, there’s always a prior authorization with ruxolitinib because it is a new medication. How does that work in your practice with the pharmacist? Do they typically reach back to you? How does that process work in your practice?
Dr. Chesahna Kindred: PAs (prior authorization) is the bane of my day and my staff’s day. We hate it. I hope that rings loud and clear. It wastes our time. Yes, I wanted the patient to have the medication, and then we have to confirm that we wanted the patient to have the medication. In an optimal model, if we write the prescriptions, yes, I did want the patient to have it. In the medical record, they should be able to see—we have to get to the point where you can see—that, yes, this person has vitiligo from the code. We literally see fewer patients because of the time needed for these extra steps. In the optimal model, when we write a prescription, let the patient have the treatment.
The other part that we run into is, and we just went over earlier, that these patients are affected psychologically, psychiatrically. We have hurdles for the patient to get adequate access to mental health and at least have it in between. Unfortunately, our patients find themselves going to Facebook support groups, where they might not be getting the best information. The optimal model would be to look at the data. The medication works, the medication is safe. Let them have it. It’s cheaper than phototherapy for the patient because they don’t have to come into the office. If we refer the patient to psychiatry, let them go. This sounds like medicine 101, but an optimal model will remove these barriers for our patients to live their best life. We don’t just want to repigment. We want the whole patient whole.
Dr. Heather Woolery-Lloyd: That was such a good summary of the frustrations in practice when we’re trying to get our patients the best treatment possible. I love how you summed that up for us, because I think access is a real concern. We always want to make sure, especially with something new, that’s FDA approved, and the only thing that’s FDA approved for vitiligo, we don’t want to limit access to that type of medication. Thank you for that great assessment.
Dr. Gary M. Owens: I wish I could make prior authorizations go away because they are a big administrative burden on the health plan too. But unfortunately, especially in our commercial world, where 60% to 65% of all health care is paid for by patients’ employers and the rest is paid for typically by the government, those questions, especially in the employer-sponsored health plans, are, what are you doing to manage the cost of these high-cost therapies? The...elephant in the room is all of this would go away if therapies weren’t as high cost as they are today. But that’s a problem I can’t fix and you can’t fix. Other countries have fixed it, but they fixed it with a whole different medical system than we have. I’m not advocating for or against that. I’m just saying that in the system we have, the reality of cost is still an issue that we have to deal with.
Dr. Heather Woolery-Lloyd: Yes, it is complicated. I think that you make such a good point, (Dr. Owens), in that all of us together, as experts, can’t solve, unfortunately, this problem because it is so complex. But it’s very helpful for everyone to understand that our goal is always patient care. I try to focus on that as much. It’s a system we have, and we have to jump through the hoops required for the system we have.
Dr. Gary M. Owens: We all have to work within it. Yes.
Dr. Heather Woolery-Lloyd: And work within it. Exactly.
Transcript edited for clarity.